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Facility Name: <br />Facility Address • <br />Telephone: <br />Person Filing <br />Report: P <br />1W RECONCILIATION i• <br />QWWMY SUMMARY REPORT FORM <br />aboveI hereby certify under Penalty of perjury that all inventory <br />variations for the - - <br />d facility were within the <br />allowable limits for this <br />quarter. <br />exceededInventory Reconciliation Sheet.) <br />Inventory variations <br />y <br />allowable limits for this <br />` - - • under penalty <br />source for the variation was <br />not due to authorized (leak) <br />release. (y <br />Sheet). les in Column <br />,, of <br />Inventory Reconciliation <br />List date, tank 1, <br />for exceeding the <br />ate <br />3. // -2 2- <br />4. /a - ?-?/ <br />5. 12- - /0�_ q71 <br />amount for all variations and the reason <br />allowable limits. <br />an mou tBeason <br />-/67-7 <br />/6 7 7 rt'• I ,� ? ,�r g C C u r �i lC 'Q'f <br />Ib 7 7 ®(-f <br />FuelY>el�uer <br />c� <br />Additional dates/amounts shall be continued on a separate <br />sheet of paper and attached. <br />If the source of the variation which exceeded allowable limits <br />was due to a leak, the incident shall be reported to Public <br />Health Services of San Joaquin County Environmental Health <br />Division, within twenty-four (4) hours and an unauthorized <br />release report submitted. <br />The quarterly summary report shall be submitted within fifteen (15) days of <br />the end of each quarter. Circle appropriate quarter. <br />Quarter 1 - January ---------- >March <br />Quarter 2 - April ----------->June <br />Quarter 3 - July ------------>September <br />Quarter 4 - October --------->December <br />Send to: SAN JOAQUIN PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />1601 E. Hazelton Ave., P.O. BOX 2009 <br />Stockton, CA 95201 <br />(209) 468-3420 <br />